Status of the problem of venereal diseases and of venereal diseases control program in the Americas

Pan American Health Organization World Health Organization

XVII

PanAmerican

SanitaryConference

XVlll

RegionalCommittee

Meeting

ProvisionalA_enda Item 35 CSP17/25 (Engo)

2 September1966 ORIGINAL: SPANISH

STATUS OF THE PROBLEMOF VENEREAL DISEASESANDOF VENEREAL DISEASE CONTROL PROGRAMS IN THE AMERICAS

The increase in the venereal diseases observed in countries where

there are well developed data registration systems seems to be a world-wide pheuomenono The seriousness of this situation led the Pan Americsm Sanitary Bureau to submit to the Directing Council, at its meeting in Mexico City

in 1964, a study on the problem of the venereal diseases in the Americas aud on the corresponding control programs (Document CD15/30) a copy of which is attached hereto (Annex 1)o Information received by PASB/WHO subsequent to 1964 appears in Annexes 2, 3, 4 and 5o Annex 2 gives the number of cases and deaths, with rates per 100,000 population, by country, for the period 1961-1964o Annex 3 gives the number of cases, and rates per 1O0,000 population, by country, of early syphilis during the period 1957-1964o Annex 4 shows the number of cases of early syphilis and of all forms of syphilis for selected countries in 1964o Finally, Annex 5 gives the number of cases of gonococal infection and the rates per 100,000 population, by country, for 1964o

Our knowledge of venereal disease cases is limited because of a series of factors° In many cases the patients have recourse to self-med-ication, to "amateur doctors", or to professional workers other than

•, physicians, who do not report the cases known to them° Furthermore, med-ical practitioners only inform the health authorities of some of the cases

J _ among their patients°

To all this is added the fact that, in the case of syphilis9 the various methods of classifying the disease differ, even in one and in the same country° For example, it is not always possible to compare cases of early syphilis reported by one country with those reported by others for t_s reason°

As a result of the regression of the venereal diseases after the discovery of penicillin,physicians and medical students witnessed the gradual disappearance of these diseases and at the same time their

CE£19/25 (Engo) Page 2

a recrudescence of the venereal diseases, the problem of diagnosis is a contributory factor in our failure to detect cases°

The venereal diseases should be regarded, in every respect, as communicable diseases, which they are in actual fact_ and should not be artificially separated from the others by giving them special character-isticso Epidemiological investigation, especially in syphilis, is the method of choice in the search for sources of ir_ection and the prevention of new cases° Special techniques are used for this purpose -the

investiga-tion of contacts being particularly important- and, in view of the nature of the problem involved, call for specially trained persom_elo

¢

The venereal diseases should be diagnosed by means of clinical examination, backed up by laboratory tests and epidemioiogical inve stiga-tion° Laboratory techniques for venereal _isease diagnosis have been simplified and improved in regard to both sensitivity and specificity° Their correct application would greatly contribute to the discovery of new cases, their treatment and the prevention of the disease°

Health education, which has intentionally been left until last, is fundamental for permanent activities in venereal disease control programs°

The Directing Council, at its meeting held in Mexico City in 1964, requested the Director in Resolution XXXV (Annex 6), "to undertake a special study of the current situation of the venereal disease problem in the countries of the Americas, for the purpose of preparing a proposal for a continental program to control these diseases, and to report thereon to a future meeting of the Directing Council"° For reasons of an economic nature, and because of prior commitments, it has not been possible to make the study which the Directing Council requested° Nevertheless, it is hoped to undertake it in the near future? and report to the Directing Council at the appropriate meeting°

The PASB carried on various activities in connection with the

venereal disease problem in the years 1965 and 1966o In 1965, a Pan ,'

American Seminar on Venereal Deseases was heldo This Seminar was spon-sored by the Government of the United States of America and the Pan American Sanitary Bureau_ and took place at PAHO Headquarters, in

$#asi_ington, Do Co The Seminar dealt with 4 items_ namely:

lo The Importance and Epidemiologic Characteristics of Venereal Disease_

2o The Importance of Case-Finding in Venereal Disease Control;

3o Clinical and Laboratory Diagnosis of Venereal Disease, and

CSP17/25 (Engo) Page 3

The presentation of each item was followed by a commentary given by a specially qualified expert° The discussions resulted in the prep-aration of a final report containing valuable recommendations° The work of the Seminar was published in the January, February, March and April 1966 iscues of the PASB Bolet_no In addition_ PAHO Scientific Publication

137, issued in June 1966, contains all the papers presented at the Seminar and the final report°

" In 1965 the translation into Spanish was completed of the "Serologic Tests for Syphilis" (1964 edition), prepared by the Venereal Diseases

- Branch, Communicable Diseases Center_ Atlanta_ Gao, of the United States Public Health Services° It is hoped to distribute the Spanish version of this manual in the course of the present year° Special laboratory techniques for venereal disease diagnosis not included in the "Serologic Tests for Syphilis", and which were presented at the Seminar on venereal diseases in 1965, have been translated into Spanish and appear in PAHO Scientific Publication NQ 137o

In 1965, with the collaboration of the Venereal Diseases Branch of

the United States Public Health Service, the Pan American Sanitary Bureau held 2 courses on laboratory techniques for the diagnosis of venereal dis-eases, in Chile° Two similar courses were held in Argentina in 1966, again with the collaboration of the Communicable Diseases Center, Atlanta, Gao

Studies have been commenced for the preparation of a uniform system for data registration and for reporting on venereal disease control

progr_nso A glossary of terms is also in preparation° It is hoped that as a result of future discussions with experts from the countries of the Region it will be possible to agree on the use of a single clinical clas-sification of syphilis so as to enable comparative studies of the problem to be made°

The pl_nin'g,programming and evaluation of venereal disease control programs calls for administrators in order to direct the programs in an • effective, economic and rapid ma_nero PASB/WHO is in a position to give

countries the necessary technical assistance for the training of such personnel°

Fellowships awarded by the Pan American Sanitary Bureau have helped to train personnel in various aspects of the venereal diseases and their

control° In coming years, the Pan American Sanitary Bureau hopes to extend this technical assistance program°

0SP17/25 (Engo) •_NNEX I

REV1-EWOF THE STATUS OF THE VENEREAL DISEASE PROBLEM AND CONTROL

directing council regional committee

HEALTH

HEALTH

ORGANIZATION

ORGANIZATION

XV Meeting XVI Meeting

Mexico, D°F. August-September_mll 1964 _i

Provisional A_enda Item 33 CD15/30 (Eng.)

15 July 1964

' ORIGINAL: ENGLISH

REVIEW OFTHE STATUS OF THE VENEREAL DISEASE PROBLEM _D CONTROL PROGRAMS IN THE AMERICAS

I. IMPORTANCE OF THE PROBLEM *

The venereal diseases are truly word-wide in occurrence -- but the exact extent of the problem is unknown. Variations in morbidity reporting practices from country to country and, indeed_ within

countries, make it difficult to compile reliable statistics relating

to the incidence and prevalence of the venereal diseases.

In the United States, where a vigorous venereal disease control program has been carried on since 1940, the figures from a recent

survey of case reporting by private physicians indicate that only ll per cent of the cases of infectious syphilis, 38 per cent of the cases of other stages of syphilis, and ll per cent of the cases of gonorrhea treated by private physicians during the survey period were reported to the health department°

In spite of the under-reporting problem, Guthe and Hume estimated in 1948 that at least two million cases of new venereally acquired

syphilis occurred in the world annually. In terms of prevalence, they estimated that a total of 20 million cases of syphilis existed among

persons over 15 years of age throughout the world. There has been a tremendous increase in the world's population since 1948o There have been similar increases in factors affecting the rate of spread of

syphilis such as greatly increased mobility and migration, as well as an apparent increase in sexual promiscuity. A recent global survey

conducted by the World Health Organization covering 106 countries and areas established the fact that there has been a sustained rising

incidence trend of early syphilis in all regions of the world. With

* The information contained in the first part of this document has been

COlS

/

30(Eng.)

Page 2

these considerations in mind, along with the large degree of

under-reporting of treated cases, it is now conservatively estimated that at least three million cases of new venereally acquired syphilis

occur throughout the world annually and that the present reservoir of syphilis, that is, prevalence, is at least 30 million cases.

Even more important than the world-wide recrudescence of

_cquired syphilis is the potential disability and premature mortality that can be expected to occur among persons who do not receive treatment. For example, among the millions of syphilitics throughout the world who

will not receive the benefit of diagnosis and adequate treatment, it can be predicted from the Oslo study by Bruusgaard that one in 200 will become blind; one in 50 will become insane because of central nervous system syphilis; one in 25 will become incapacitated with tabes; and one in 15 will become disabled with cardiovascular syphilis. Furthermore, the Tuskegee, Alabama Study indicated that life expectancy is reduced 17 per cent by untreated syphilis and that in 30 per cent of the

syphilitic patients examined at autopsy, syphilitic involvement of the cardiovascular or the central nervous system was established as the primary cause of death.

In addition to the disabling factors and premature deaths caused by the late manifestations of the disease, there is tremendous economic loss due to uncontrolled syphilis. Just to consider one factor of the economics of the disease, in the United States alone, there are at the

present time 24,000 patients in mental hospitals because of psychoses due to syphilis. This poses a financial burden to the taxpayer of

$49,000,000 per year for their maintenance. In addition, it is estimated that there are 12,200 persons in the United States of America disabled with syphilitic blindness whose maintenance cost the taxpayer $5,000,000

annually. Unfortunately, corresponding economic data for other countries of the world are not available. Syphilis must take a tremendous toll

each year throughout the globe in terms of blindness, insanity, other disabilities, and death.

Gonorrhea is even more poorly reported than syphilis. The ratio

of gonorrhea to syphilis cases admitted to clinics indicates that about four cases of gonorrhea occur to one case of syphilis. Applying

this ratio to the estimated world-wide incidence of syphilis, it is

conservatively estimated that at least 12million cases of gonorrhea occur throughout the world each year. Although the late manifestations of gonorrhea are not as severe and insidious as those due to syphilis, gonorrhea does cause pelvic inflammatory diseases in females, sterility in both females and males, epididymitis, salpingitis, other serious conditions, and, on occasion, death.

In spite of the widespread occurrence of syphilis throughout the world, present case-finding techniques plus the efficacy of easily applied penicillin therapy provide adequate tools for the control of

CD15/30 (Eng.) Page 3

As to gonorrhea, the incidence of which has also been steadily increasing throughout the world, there have been some breakthroughs in

gonorrhea research which will make the diagnosis of gonorrhea in the female much easier and more certain than in the past. Such progress offers hope for the eventual control of this venereal disease.

IMPORTANCE OF THE PROBLEM IN THE AMERICAS

Venereal syphilis continues to be an important communicable disease problem in all regions of the Americas. While yaws occurs mainly in the Caribbean Islands and _ome countries in South America,

and pinta occurs in Mexico and some South American Countries, venereal syphilis is widespread throughout alS three regions. Syphilis

consistently ranks among the top ten notifiable diseases for American countries (Table 1).

There has been an increasing trend in the incidence of early syphilis in the Americas since 1957 (Table 2). In 1962 reported cases of all stages of syphilis per lOO,O00 population were 77 and 64,

respectively, in Middle and Northern America as compared to 48 in South America (Table 3). Reported cases in Northern America have

increased slightly. This upward trend may be due to intensified case-finding activities in the region. On the other hand, the number of reported cases of syphilis has decreased slightly in Middle and South America. This downward trend is difficult to evaluate because

of lack of reports from several countries for one or more years.

Gonorrhea also consistently ranks among the top ten notifiable disease for American countries. There has been an upward trend in

reported cases of gonorrhea in all three regions (Table 4). In 1962 reported cases per lOO,O00 population were 151, 140, and lll respectively in South, Northern, and Middle America. The gonorrhea rates are

approximately three I two, and one and one-half times the syphilis rates . respectively in South, Northern, and Middle America.

The other venereal diseases --chancroid, lymphogranuloma

_ venereum, and granuloma inguinale-- are reported from all three regions of the Americas, although the numbers are not sizeable. Of some

significance is the chancroid rate for South America which is

approximately one-half the syphilis rate (Table 5).

II. GENERAL CONSIDERATIONS

The recrudesence of venereal diseases is world-wide. Nevertheless

CD15/30 (Eng.) Page 4

other than physicians, treatments by physicians and institutions that do not report cases_ etco our knowledge of the extent of the problem is incomplete. The customs of the population and the reserve which surrounds the disease are other reasons why official services register only a meager proportion of venereal diseases patients. Improvements in diagnosis, notification, and registration of cases should lead to a gradual rise in the venereal disease rate.

The importance of venereal diseases as a public health problem and their impact on society make it necessary to organize or intensify national programs for the control of these diseases. These programs must be conducted in the light of the new concepts of venereal disease

control and new techniques for case-finding and case-investigation and for diagnosis, specially the diagnosis of syphilis.

Venereal diseases must be regarded as only one of the communicable diseases for whose control national health services are responsible.

Venereal disease control programs must be long-term and conducted

without interruption, since past experience shows that the value of isolated campaigns is ephemeral.

New case-finding methods based primarily on the epidemiological investigation of patients and s,_spects, of their contacts, and of persons in the social milieu where patients and suspects are likely to be found have proved to be valuable whenever employed by experts

who investigate carefully, prudently and discreetly. This necessarily implies thorough preliminary training of personnel.

The new laboratory techniques developed in recent years for the diagnosis of venereal diseases are both sensitive and specific. The diagnosis of syphilis have benefitted enormously from these new techniques.

Mention should also be made of the treatment of all the venereal

diseaseswhich has now been put on a systematicbasis.

It must be emphasized that correct application is essential and that the patient must not be regarded as cured until the pertinent tests give satisfactory results.

Health education, which is an important factor in all health

C

D

1

5

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30 (

En

g.)

Page

5

a) To provide

a better knowledge

of venereal

diseases,

their

dangers, and their prevent

i

on.

b) T

o

induce

t

he patient, or suspect, to seek treatment from a

p12ysician

o

r medical institution.

To induce the patient or

suspect to n

o

t

i

fy the

v

enereal disease con

t

rol agency of

possible s

o

urces of infection and of the persons exposed to

•

the risk of infectionso they can be treated.

c) To obtain

the cooperation

of medical

practitioners

and medica

l

•

i

nst

i

_

ti

ons

i

n un

d

ertak

i

ng co

o

rdinated act

i

v

i

t

i

es for t

h

e

control of venereal diseases.

Notif

i

cation of patients is a

preliminary step in th

i

s d

i

rection.

The organization

of a system of data registration

must be the

starting

point for the organization

of venereal

disease

control programs

.

In add

i

tion, prec

i

se objectives must be defined

, a

time-table of

operations must be drawn up, and provi

si

on must be made for periodic

evaluati

o

n.

The Pan American Health Organization, rec

o

gnizing the

imp

o

rt

a

nce

o

f venereal diseases as a health problem in the Region of

the Americas, will pr

o

vide Governments with all possible technical

assistance, subject only to budgetary l

i

mitations.

In order to pr

ov

ide an

o

pportun

i

ty for an exchange

o

f

o

pini

o

n

s

and t

o

unify thinking ab

o

ut venereal

d

iseases and ab

o

ut what the

countries

o

f the Region can do in this regard, a Pan American Seminar

on the C

o

ntrol of the Venereal Diseases will be held

i

n 1965 in the

United States of America, with the collaborati

o

n of the United States

P

ublic Health Service.

It is hoped that this

i

nternati

o

nal meeting

will be the starting p

o

int of concerted acti

o

n by the c

o

untries of the

R

egion f

o

r the c

o

ntr

o

l of venereal diseases_

"T

,, ,!5

t :

'_o ( P

,

ng

.

)

TABL

E

2

E

ARLY SYPHIL

I

S CAS

E

S P

E

R I00,00

0

POPULAT

IO

N

OV

ER

15 Y

EA

RS OF AG

E I

N TH

E

AM

ER

ICAS

Year

Cas

e Rate

195

0

4

6.3

1

95

1

33.8

1

952

23.9

1953

23.2

19

5

4

1

7.

0

1

95

5

12.0

1956

11.9

195

7

1

1

.

7

1

9

58

12.8

1

95

9

14

.

I

1

9

60

1

7

.

0

t

0D15

/

30(Zn_.

)

TABLE 3

REPORTED CASES OF SYPHILIS WITH RATES PER I00,000 POPULATION

IN THE THREE REGIONS OF THE AMERICAS, 1959-1962

Year Northern Middle South

Number Rate Number Rate Number Rate

1959 122956 63.2 63530 98.7 35586* 52.5

1960 124184 62.8 63102 95.0 36468* 52.6

1961 126979 63.1 62049 89.7 34170 48.6

1962 128682 63.9 54146 77.3 33968 47.8

* Excluding Brazil - no data for 1961 and 1962.

CD15

/

30(Zng.)

TABLE 4

. REPORTED CASES OF GONORRHEA WITH RATES PER 100,000 POPULATION

IN THE THREE REGIONS OF THE AMERICAS, 1959-1962

year Northern Middle South

Number Rate Number Rate Number Rate

1959 255175 131.1 75238 116.9 71040* 104.9

1960 274741 138.9 69466 104.5 75849* 109.5

1961 280675 139.4 69607 100.7 87691 124.6

1962 281514 139.8 77827 III.I 75258** 150.?

* Excluding Brazil - no data for 1961 and 1962

CD15/30 (Eng.)

TABLE 5

, REPORTED CASES OF CHANCROID WITH RATES PER I00,000 POPULATION

IN THE THREE REGIONS OF THE AMERICAS, 1959"1960

Year Northern Middle, , ,, • South,

Number Rate Number Rate Number Rate

1959 1545 0.8 6836 10.6 21073 31.1

1960 1683 0.9 8595 12.9 13784* 24.3

ANNEXII

SYPHILIS - REPORTED CASES AND DEATHS WITH RATES PER I00,000 POPULATION, BY COUNTRY

1961-1964

Cases ' I)eaths '

Country Number Rate Number Rate

...

"

96.3

i.!964

:196i.1

,

Argentina 4397 5149 614 c 6195 20.9 24.1 28.4 28.1 ... _)302 ... l._ --_ ._: Bolivia b) 133 89 b) 9Cb) 124 3.8 2.3 2.5 3.4 ... . ...

Brazil (c)

Canada

2_i 2;_ 2_

2_

1_:_

%:i 1;f

;

I1;t:;

.

362 335

281

.. 2.7 2.5 2._ ...

Chile * 3705* 3106 * 304C* 3502 195 153 125 14_ 2.5 1.9 1.5 1.8

Colombia d)101661)igg32_e)978_e)14992 7319 8916 6912 8518 210 195 T9C 19_ 1.3 1.2 "1.1 1.1

CostaRica 597 1200 128' I170 48.7 94.2 95.8 84.4 15 8 12 IE 1.2!0.e 0.£ 1.3

Cuba 482 805 1691 1863 6.9 11.4 23.4 25.1 134 113 I14#Ii_ 1.9 I.C l.e 1.6

Dominican Republic 12040 10494 7113 12639 382.8 322.4210.9361.7 121 62 5c 3c 3.8 1.9 I.'_ I.I

Ecuador d) ...if) 228 45 48 5C 3] 1.0 1.0 1.l 0.6

mSal_dor

d),5_

6_i_ 779_ 834940_:_43_:_28_:_29_:_88 90 22 ... 3.5 3.4 0._ ...

Guatemala 906 816 801 1186 23.1 20.1 19.2 27.5 9 4 4 ...! 0.2 0.I 0.1 ,., Haiti 4944 5201_/ 340[_ 3172 116.4 119.7 76.6 69.71f) 1 f) - . .... ...

Honduras 2285 d) 2345 d) 161c_ _) 1981 120.5 246.3 161.9 159.0 5 6 8 5 0.3 0.3 , 0.4 0.2 Yamalca 9748 277e 229E 1774 596.2 169.1136.2102.71135 ... 102 i00 8.3 ... 6.C 5.8 Mexico 19254 18219 2006C 17697 53.3 48.9 52.2 44.61525 49_ 442 487 ].5 1.3 1.2 1.2

Nicaragua 1 514 _/ 1537 3 10E 1029 104.2 102.7 201.2 64.4! i 4 - 0:1-, 0.3 Panama 151 37(] 20( 239 13.8 33.0 17.3 20.2_ 21 7 II 15 1.9 0.6 I.(] 1.3

Paraguay(d,g) 1722 1835 1611 2008 144.7 150.4 146.9 182.51 28 23 31 ... 3.1 2.5 3.2 ...

Peru(d,h) 3475 3872 367c_ 3320 71.3 75.1 76.4 61.5 39 52 52 40 1.0 1.2 1.1 0.8 Trinidad and Tobago 32? 38F e)'371 ... 36.6 41.8 .... 43 41 40 / 35 5.0 4.6 4.3 3.7 United States 124658 126245 12413_I14314 i 68.1 67.9 65.8! 59.7'2850281126662619 1.6 1.5 1.4 1.4 Uruguay 234 203 161_/ 273_ 9.1 7.8 6.1i 10.2 95 ... 71 ... 3.7 ... 2.7 ... Venezuela (d) 9920 9127 948C 9533.196.5 172.9 171.6 165.7 154 180 150 136 2.0 2.3 __1.8 .1.6 Antigua 256 . 18_ 104' 457.1 ... 318.6 173.3 18 17 17 932.1 29.3 i28._ 15.0 BahamaIslands _ 19 141 3£ 921 15.6 10.9 22.4 65.2i ... 1 ..,. 6 ... 0.8 .. 4.3

Barbados * _i a *i *I * * * 28 29 2712412.0 [2.3 11.3 9.9

Bermuda i0 _ 2_ 12i 22.2 10.9 48.9 25.0_ I 1 ... 2 2.2 2.2 .. 4.2

British Guiana * 334 * 415 * 80( * 2361 ... : - - 1 ... - - 0.2 ... British Honduras 659 648 . 790'701.1 668.0 . .. 767.0[ - - 1 2 - - 1.C 1.9

CanalZone 24 17 1( 69 55.81 37.8 20.0:127.8' - - 2 - - 3.7

Cayman Islands _/ 1 3 ] 4 (II.I_ (33.3) (iLl] _ I . _ . ... ,_

Dominica ... 55 IL _ 771 ... 90.2181.0120.31"" 4 6 6.6 9.5 ...

FalklandIslamds - - ... ! - ...', ...

FrenchGuiana 84 98 "4[ 54:247.1288.2137:]150.0! - ...,...,...

-Grenada 687 52c_ ... i 763.3 ... 575.( 7 2 5 7.8 2.2 5.4 ...

•

Cuadelo._e

644 i_

....

460229.2183.4.. 1%:_ 51

1 ...'"_8.1

0.3 ..

0.7

Martinique 26 9 i_i)357 9.0 3.1 115.2 .... . ...

Montserra_ 24 - .! 11184.6 - ..., 84.6 I ... - 7.7 ...

-Netherlands Antg/es * * *i * *! * 4 2.1

PuertoRico 1180 1056 140] 1581 49.0 42.9 55.( 61.3 49 361 34 38 2.0 1.5 1.3 1.5

St. Kitts - Nevis

andAng_11a 28 22 12_ 5 47.5 36.7 19._ 8.5 2 1 - ... 3.'4 1.7 -- ...

St. Lucia 391 668 149_ 196 439.3 726.1 158._ 213.01 4 3 5 ... 4.5 3.3 5.3 ...

St.Pierreand

IV_quelon - - .../ .... i ...

St.Vincent ... 12 ... 14]_ ...i 2 5 - ... 2.4 6.1

-Surinam (h) "'* * 874d) 25[) '_ .. 87.81 11 6 6 10! 8.8 2.0 1.9 3:{

Turks and CalcosIs. ""4 1 3 4 - (66:T, (16.7) (50.0: - ... - - ...

VirginIslands(I/K) - - ... - . . .I ...

ANNEX IV

Reported Cases of Syphilis by Sex in Selected Countries, 1964

Early syphilis Syphilis I a ll forms

Ratio Ratio

Country Male Female M/F Male Female M/F

Bolivia 51 73 0.7

Canada (a) 571 238 2.4 1 681 1 036 i_6

_

o

_

o

_b_

cb_

767473_ _o

,.

o_

'

_J

Jamaica 131 75 1o7 999 775 1.3

Panama(c) ... ll2 88 1.3

Trinidad and Tobago (c) 25 17 1.5 209 176 1.2

United States 14 305 8 663 1.7 63 356 50 958 1.2

Uruguay (c ) ... 95 65 1.5

ANNEX

V

REPORTED CASES OF CERTAIN NOTIFIABLE DISEASES WITH RATES PER

100,000 POPULATION IN THE AMERICAS, 1964

Encephalitis,acute infectious Gonococcal infection Hepatitis,infectious

(082) (030-035) (092)

Area

1959-63 1963 1964 1959-63 1963 1964 i1959-63 1963 1964 Median Number Number Rate Median Number!Number Rate IMedian Number Number Rate

Argentina 496 579 648 2.9 9 389 I0310 ii051 50.2 2402 2447 2 931 13.3

Bolivia I i - 92 62 78 2.1 1 ...

Brazil ... a) 99 ... a) 4_,4 ...

Canada

b) 9 b) 57b)

.-)10077

c)10077

42.7

Chile 90 83 120 1.4 * "1392 * 902 249 249 618 7.3

Colombia d) 102 d) 339 230 1.3 d)47229ie)46285e)41972 240:4 * * °..o

.

CostaRica

8

14

11 0.8 22872227 18 8 131.8

321

684

50:i

Cuba 26 38 32 0.4 ! 372 787 866 11.6 554 4659 5249 70.6 DominicanRepublic ... 14028 17347 502.5 ... 186 2 0. 1

Ecuador ... 51f) 13 ... f) 71 ...f) 91 ...

El Salvador d) - - d) 3 _.2_, 4354 2909 i03:(3d) _.48 994 1069 87. 9

Guatemala 2 "11 0.3 8226 3848 3274 76.1 * * *I *

Haiti "'4 ¢ - _/ - 4736¢ 3849 ¢ 3491 76.7 80 ... _/ 1381 3.0 Honduras 8 d) 24 d) 18 1.4 4618 d) 3463 d) 357 28.7 ... d) 252 20.2 Jamaica 4 2 5 0.3 27516 34228 28220 1633.1 164 i00 71 4.1 Mexico b) 18 b) 18 31 0. 1 18882 18784 18367 46.3 3025 2961 2940 7.4

Nicaragua ... 766 629 1942 121.6 ..

Panama

603 649 62551.7

li

Paraguay (d) 29 39 29 2.6 473 473! 396 36.0 :19;7 182 99 9.0

Peru (d) 53 53 151 2.8 6852 8086! 7978 150.5 2383 2451 3211 60. 6 TrinidadandTobago 1 6 0. 6 4494 7 978 * 3 574 6 * 4 United States g) 2 248 g) 1 993 2 002 1.0 263 708 278 289 300 667 157:1 _)42974 c)42 974 c)87 740 19: Uruguay 32 36 / 17 0. 6 227 227 _/ 81 3.01 ... _/ 1338 49. 9 Venezuela (d) 74 b)10145 b)ll 540 200. 6 18800 18910 20652 359.0 " " * * * *

Antigua - - 156 117 105 169.4 - 1 1.6

BahamaIslands 3 1 0.7 3291 17 236 176.1 9 f) 14

Barbados * * * * * * * * ""* * * ""_

Bermuda - _/ - - 102 _/ 138 217 452.1 5 _/ 8 6 12.5 British Guiana ... * * * "2382 * 5910 "2114 ... * * * British Honduras - 1 _/ - - 328 * * * " " 1 3 _/

CanalZone - _ - - 67 94 280 518.5c) 17 c) 14 _ 13 24.1

Cayman Islands - _/ - 4 4 _ 37 411.1 ... 1 _/

Dominiea - / - . 225 _ 281 432.3 . 6 _/ 12 18. 5

FalklandIslands - i0 "_. ...

French Guiana - "'" .... " 166 i_,9 "82! 227:8 ...

-Grenada - . ... 781 1014 .. - ...

' Guadeloupe - _/ - - 2_/ - 6 _.: 0 ...

-Martinique - - ¢ - - - ¢ 5 i.6 - ..

Montserrat - 13 i00.0 i (7"7)

NetherlandsAntilles * * * * * _" * * * * -

-i

PuertoRico - 18 i 0.0 2719 2570 2840 109.9c) 949 c) 949 c)1159 44.9

St. Kitts-Nevis and

Anguilla 1 - _/ - - 419 223 _/ 87 140. 3 19 19 ... St. Lucia - - * * 1 635 716 _/ 1093 1 188.0 ... - ... St. Pierre and

Mtquelon ... _/ ... _/ 4 (80.0) ... St. Vincent ... •...

Surin

...

...

Turks andCalcos

Islands _/ - 64 95 / 23 383.3 - _/ 1 (16. 7)

VirginIslands(Ut0 ...

VirginIslands (US) - ,_/ - 95 / i93 263 641:5 c) 1 c) 3 ...

(a) Data for Federal District, States of Guanabara and (d) Reporting area.

Pernambuco, and capitals of I0 other states (9 (e) Excluding blennorrhagic ophthalmia of newborn (033 pt. ).

otherstatesfor infectioushepatitis). (i)Hospitaldata.